Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact Phone *

(###)

###

####

Birthday *

MM

DD

YYYY

Have you visited the doctor in the last year *

Yes

No

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you perform physical activity? *

Yes

No

In the past month, have you had chest pain when you were not performing any physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes

No

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? *

Yes

No

Have you ever had any surgeries? *

Yes

No

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? *

Yes

No

Are you currently taking any medication? *

Yes

No

Does your occupation require extended periods of sitting? *

Yes

No

Does your occupation require extended periods of repetitive movements? *

Yes

No

Does your occupation require you to wear shoes with a heel (dress shoes)? *

Yes

No

Does your occupation cause you anxiety (mental stress)? *

Yes

No

Do you partake in any recreational activities (golf, tennis, skiing, etc.)? *

Yes

No

Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? *

Yes

No

Have you ever worked out with a Personal Trainer before? *

Yes

No